The Hastam Blog

Professor Andrew Hale explains.

Dictionary definitions of resilience emphasise the ability to bounce back from adversity or hard knocks. That would cover a company responding to a disastrous fire by reopening production facilities in a temporary building, or a chemical works responding to a major leak by full openness to the local residents about the causes of it, and involvement in decisions about future risk controls, or a power company drafting in extra staff to restore power to residents cut off by a heavy snowfall. However, in the last decade ‘resilience’ in the world of safety and risk management has also come to mean the ability of an organisation or its staff to anticipate and prepare for such disturbances, to prevent them happening, or at least prevent them escalating to a disastrous level. So, to the reactive resilience, we have now added proactive resilience. That usage is now bidding fair to be the new buzzword for safety management after ‘safety culture’.
The pioneers of resilience engineering are researchers and consultants like Erik Hollnagel, David Woods, Richard Cook and John Wreathall. The book ‘Resilience Engineering: concepts and precepts’ provides a good set of readings to stimulate the mind and set you on the track to implement the ideas. We can summarise what their authors say about resilience in the following list of characteristics :
1. Conflicts of objectives and actions between safety and other objectives are explicitly managed, especially between short and long-term objectives, and risk control measures are strengthened rather than eroded in times of production pressure or other competing objectives to be faster, cheaper and better
2. Enough redundancy, buffering, flexibility, tolerance and margins are built into the system and retained, especially in times of limited resources, to cope with rapid changes and peaks in demand
3. Capacity is explicitly planned and retained to cope with unexpected and unpredicted disturbances
4. Past good performance in safety is not seen as a reason for complacency but for added vigilance; a climate of creative mistrust
5. The organisation has a clear, explicit and integrated picture of all its risks, the scenarios which result in them and which measures are designed to control each one
6. Risk assessments are constantly kept up to date with new evidence from the own, but also other organisations; a characteristic of a learning organisation
7. Particular attention is paid to activities that span the boundary between groups, departments or independent organisations, so that their risks and the responsibilities for controlling them are identified, and those responsibilities are allocated in an overlapping way to allow for mutual checking.
8. There is a devotion to safety, characterised by a chronic unease, even when everything appears to be going right
9. Whistle-blowers on safety issues are valued, even when they are wrong
10. Local (front-line) staff is competent and trusted to cope safely with exceptions to safety rules, but is expected to explicitly report and critically assess those coping strategies.
11. Safety is considered and built inherently into the system and its activities and not bolted on after the conception and design stage
I guess for some of you, some of the topics may be familiar from the older notions of HROs (High Reliability Organisations) or maturity scales applied to safety management systems. They may even already be covered by existing aspects of your safety management system. But that will probably leave several that you haven’t thought of, or are still on your wish-list and you are working out ways to achieve. Some may even be new to you. The challenge now is to find ways of implementing these seemingly simple sentences and auditing whether that has been a success.

You may be aware that Hastam has been involved in the investigation of some of the principal safety incidents in the UK in the last decade – for
example, the explosions at Port Talbot and Buncefield, and the rail crash at
Potters Bar. Professor Richard Booth was involved in all three
investigations and has now written on the importance of Hindsight Bias and
a contentious, albeit personal, account of its effects on the investigation
of the Buncefield explosion. While everyone ‘knows’ about Hindsight Bias,
its manifestations are much more detrimental, multi-faceted and subtle than
they might at first appear. Richard’s analysis is underpinned by a study of
the seminal research literature which takes the story into unexpected
directions.

Professor Booth’s discussion about the events leading up to the explosion
and his critique of the investigation and the impact of Hindsight Bias on
the conclusions are an education in themselves. In addition, his
explanation of the difference between root causes and underlying causal
factors may help you to ensure that you dig deeper in future
investigations. The paper of course also alerts you to the probability that
everyone involved in incident investigations, despite their best efforts,
may be biased by hindsight.

Here are the links for you to download the paper (full or shortened version) and read it for
yourself:

http://www.hastam.co.uk/publications/2012/hindsight-bias-short-01-2012.pdf

http://www.hastam.co.uk/publications/2012/hindsight-bias-full-2012.pdf

If you would like to learn more, Professor Richard Booth is speaking on this subject at this year’s IOSH Conference in Manchester, March 6th and 7th. He will also be available for a chat, along with other Hastam colleagues, at the Hastam Stand. We look forward to seeing you there.